American Cremation and Funeral Service | Modern Service with Traditional Values

PRE-PLANNING

Pre-planning is planning today for tomorrow. It allows you the opportunity to select the type of service you desire. Pre-planning will give you and your loved ones a greater peace of mind knowing that your wishes will be carried out and the expense will not be a burden to your loved ones. If you’d be interested in one of our Preneed Specialist contacting you, please complete the form below and someone will contact you.

Name

Email Address

Phone Number

Address (Street, City, State, Zip Code)

County

Birth Date

Birth Place (City & State)

Occupation

Marital Status

If married, Date & Place of Marriage

Spouse (Wife's Maiden Name)

Physician

Years of Education

Veteran? (Branch of Service)

Father's Name

Mother's Name (Maiden Name)

Next of Kin (Relationship)

Next of Kin Address & Phone Number

Place of Service

Clergy

Graveside By

Music (Requests, Vocalist, Musician)

Visitation (Public or Private)

Type of Disposition & Place of Disposition

Block

Lot/Section/Tier

Grave(s)

City & State

Casket/Cremation Container

Outer Burial Container/Urn

Bearers

Surviving Relatives (Name, Relationship, City & State)

Biographical Information (Details of life, career, church, organization membership, etc.)

Insurance

Personal Request (Clothing, Jewels, Flowers, Memorial Contributions, Etc.)

Number

12 + 4 =

“Modern Service with Traditional Values”

1204 Person St. ∙ Durham, North Carolina 27703
Phone: 919-596-6300 or 919-598-8300 Fax: 919-598-9810
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